Clinical Risk Adjustment

Using Licensed Nurse Practitioners, SCCP performs a comprehensive in-home health assessment needed to support medical risk adjustments and close gaps in care for Medicaid and Medicare members.  Our Clinical Risk Adjustment Services include:

  • Reviewing prior years diagnosis history.
  • Conducting and In-Home Assessment of current health conditions including ordering labs and diagnostic tests where necessary, and reviewing medications.
  • Completing and accurate and substantiated clinical profile of member.
  • Applying correct codes to all clinical diagnosis.

Follow-Up After Hospitalization

Utilizing LCSWs and Care Navigators, SCCP provides telephone-based follow-up after hospitalization (FUH) support services for health-plan members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnosis. Our FUH services include 7-day and 30-day mental health assessments, and care coordination support.

New Member Onboarding

SCCP believes that timely and effective outreach to new members can significantly impact health outcomes and reduce the overall cost of care for health plans. Therefore, our onboarding services provide High Touch, new member engagement support.

This initial encounter with a new member is designed to start the process towards achieving high member satisfaction and retention rates, by creating a positive first impression, establishing trust, addressing questions, and educating the new member on how to access the services they need.

Onboarding services for new members include:

    • Member Welcome Encounter
      • Introduction and Welcome Call
      • Verifying or Updating Demographic Information
      • Verifying New Member Receipt of Welcoming Materials
      • Confirming PCP Assignment
      • Completing Health Risk Screening
      • Addressing New Member Questions and Concerns
    • Location of “Hard-to-Find” Members
      • Skip Tracing
      • Partnering with Community Stakeholders to Locate Members

Clinical Care Management

SCCP is uniquely positioned to provide comprehensive, person-centered, care coordination services, for high-risk and high-cost populations. Our integrated ecological model of Care Coordination aims at addressing the inter-relational aspects of physical, psychological, and social determinants of health status, through providing a comprehensive array of coordinated, timely, and accessible services that are culturally competent. These services are provided by Clinical Care Managers (RNs, LCSWs) with support from Navigators (CNAs, CMAs).

Our Care Coordination activities include:

    • Health Risk Assessments
    • Completing Care Plans with Input from New Members
    • Conducting Member Health Education/Health Literacy Activities
    • Monitoring and Tracking of Treatment Adherence
    • Discharge Planning and Transition of Care Support
    • Medication Management
    • Utilization Management
    • Wellness Programs and Services
    • Interdisciplinary Care Team Huddles
    • Appropriate Reporting

Physician Extender Services

SCCP works with physician groups (ACOs, PHOs, IPAs) and independent physicians to provide clinical care management support beyond the physician’s office. Our physician support services include:

    • Chronic Disease Self-Management Services
    • HEDIS Compliance Support
    • Monitoring and Tracking of Key Health Indicators
    • Flagging Care Gaps
    • Real-Time Alerts Regarding Member Health Status
    • Working with Members to Schedule PCP and Other Medical Appointments
    • Monitoring Attendance
    • Behavioral Change/ Compliance Support
    • Reporting

Social Determinants of Health

We recognize that health outcomes are closely linked to non-medical issues that impact access to care and member compliance. That’s why we utilize our Navigators to help members address barriers to care, basic social needs, and other challenges to their self-sufficiency, through the following:

    • Facilitating Social Service Referrals
    • Linking Members to Community Resources
    • Assisting Members to Address Language Barriers
    • Addressing Non-Emergency Medical Transportation (NEMT) Needs